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Understanding why some people take their lives – and some don’t

Arthur Sommer Rotenberg was a doctor in Toronto with a promising career. He had a large, loving family and was both studious and athletic, once cycling from Rome to Paris with his backpack full of chemistry books.

But the sensitive, dark-haired man was also manic depressive, killing himself at the age of 36. Now, 24 years later, scientists like Dr. Sidney Kennedy are searching for new explanations for why people like Sommer Rotenberg kill themselves — and asking whether these tragic endings can be rewritten.

A scientist holds a donated brain at the Douglas-Bell Canada Brain Bank. The bank, established in 1980, has about 3,000 brains, including those donated by the families of suicide victims. (Raja Ouali / Douglas Mental Health University Institute)

Arthur Sommer Rotenberg of Toronto was 36 when he took his own life in 1992. In 1997, his mother, Doris Sommer Rotenberg, created the Arthur Sommer Rotenberg chair in suicide studies, North America's first academic chair devoted to the topic.

At the heart of his research is a new way of thinking about suicide: as a phenomenon with biological underpinnings that should be studied as its own behaviour, not just an outcome of depression or other disorders.

“I do think that there are biological factors in suicide,” said Kennedy, a professor of psychiatry with the University of Toronto. “I’ve always been struck by the fact that there are groups of depressed patients who are extremely, seriously ill, but never consider dying by suicide.

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“I think it’s important to know: what does it mean to have someone who continues to have suicidal ideation but never actually acts on it, versus people who almost immediately go to action?”

This is a central question for a wave of mental health researchers who are peering deep inside the human body, searching for the biological markers of suicide risk — a focus that is generating excitement and controversy.

Biomarkers are biological measures that can be used to predict the presence or risk of a disease — blood sugar levels for diabetes risk, for example — and Kennedy has made them a research priority in his five-year term as the Arthur Sommer Rotenberg chair in suicide studies, created by Sommer Rotenberg’s mother in 1997.

Kennedy is now spearheading an international network for studying the biomarkers of suicide. The group’s first meeting was held last month in Toronto, bringing together disparate researchers with a shared interest in studying suicide as its own behaviour — a relatively new concept in psychiatry.

“For the longest time, suicide has been conceptualized as a symptom of depression … but we know that it actually happens across a number of diagnoses,” said Dr. Maria Oquendo, a professor of psychiatry with Columbia University who attended the Toronto meeting.

“When you start conceptualizing it as a separate behaviour, then the idea that it should be targeted by specific treatments also starts to make a lot more sense.”

Many factors that elevate suicide risk are well-recognized in the scientific literature, such as mental health disorders and early-childhood trauma. Roughly half the risk for suicide is also heritable, though specific genes have not been identified, according to a 2014 review in The Lancet.

But with newer technologies, scientists can pull back the curtain on what’s really happening on a neurobiological level — allowing a more granular view of suicide that sharpens the bigger picture.

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“Yes, (suicide risk) is in the brain but it’s related to genetics and it’s also related to the story of the person, things like child abuse,” said Fabrice Jollant, a researcher with the McGill Group for Suicide Studies. “It’s a very exciting period, to be honest, with what’s happening now and all the tools we have.”

Jollant has published some of the first suicide papers using fMRI and his research is pointing towards a specific brain region associated with decision-making. In his studies, people who have attempted suicide have deficits in decision-making — an observation that offers a fresh new angle for researchers.

“So if I improve decision-making, can I make these people less fragile?” Jollant asks. “Could I reduce the long-term risk of suicide?” He has already done a preliminary study with healthy volunteers, in which he used electric currents to stimulate the same region.

“After 30 minutes of stimulation, even in healthy subjects, we could see a significant improvement in decision making,” Jollant said. “What we want to do now … is do the same thing in (suicidal) patients. Can we observe the same effect?”

Other researchers are investigating how environmental factors alter our genes and influence our lifelong risk of suicide. For example, when people suffer childhood traumas, what molecular changes are happening in the brain?

Dr. Gustavo Turecki, director of the McGill Group for Suicide Studies and co-director of the Douglas-Bell Canada Brain Bank, is studying molecular effects of childhood trauma on the brain. (Owen Egan)

To investigate, researcher Gustavo Turecki with the McGill Group is using genetic sequencing techniques and mining an invaluable resource: roughly 3,000 brains archived by the Douglas-Bell Canada Brain Bank, including several hundred donated by the families of suicide victims.

While it’s a long ways away, studying suicide on a neurobiological level could someday lead to treatments or drugs that target the biological mechanisms underlying suicide, scientists say.

“Right now, if you’re suicidal, you go to the emergency room and we lock you up in a room,” Turecki said. “It would be very good if we had effective drugs that could … decrease the suicidal thoughts or eliminate them.”

But this new focus on biomarkers has also been met with criticism. Some psychiatrists worry an overemphasis on biomarkers will cause clinicians to neglect important factors in the patient’s life.

Others accuse psychiatric biomarkers of being overhyped and point out that studies so far have used small samples. Speaking to New Scientist magazine, one Dutch-based psychology professor derided a U.S. health funding agency for spending on “biomarker porn.”

But Kennedy believes biomarkers will become just one tool in the toolbox for identifying suicide risk — and particularly useful in patients who might be unwilling to reveal suicidal urges. He also suspects this research will ultimately show there are many sub-types of suicide risk, all probably requiring different treatments.

Identifying suicide biomarkers may also play another role: reducing stigma. People who attempt suicide are still often blamed as being lazy, weak or immoral, Oquendo said — not suffering from a brain disorder.

“Until we’re able to elucidate that and communicate that to the public, I think it’ll be hard for people to understand,” Oquendo said. “The brain is so central to who we are, and how we behave, and therefore how we’re perceived.”

Dr. Sidney Kennedy holds the first university chair in suicide research in North America. He recently organized a Toronto conference of international experts in various fields related to suicide to foster collaboration and encourage discovery. The Star spoke with Kennedy about his work. The interview has been edited for length and clarity.

You hold a pretty unique position. Could you explain what it entails?

This is the first chair in suicide studies to be created in North America. I’m the second holder of the chair and the focus has really been to take the issue of suicidal behaviour and death by suicide as a major focus of research — that crosses everything from epidemiology, documenting the prevalence across different communities and age groups, even across countries, providing supportive psychotherapies and trying to identify whether medications can be helpful.

What do you find fascinating about your work?

I’ve been very interested in seeing how techniques like functional brain imaging — by that I mean seeing how the brain actually changes with certain tasks — work. For example … we can take somebody sitting in a relaxed state in a scanner and ask them to look at very disturbing pictures or very pleasant and rewarding pictures and we can actually see how different areas of the brain are activated or deactivated.

How prevalent is suicide and thoughts of suicide?

We can certainly say that, within depression for example, it’s very common to have thoughts that ‘I might be better off dead,’ or ‘I sometimes go to bed and think life isn’t worth living.’” But it’s maybe 20 or 30 per cent of people who actually seriously consider ending their life and the question would be, how could you do a better job of identifying that at-risk group?

Why is collaboration with other experts important?

The more questions you ask the larger sample of subjects you need. If I wanted to do a study and I needed 200 people that might take me 10 years, but if I have 10 groups and we’re all equally pulling our weight we might have that 200 people within our studies and protocols within one to two years. There’s a clear advantage to collaborations.

What makes studying suicide so difficult?

You’re dealing with families and individuals after they’ve lost a loved one so it’s clearly difficult and there’s a certain level of sensitivity. Also I think the fact that our medical research communities are organized by disorders has probably, in the case of suicide, not been helpful. Those are vertical silos and suicidal behaviour, suicidal ideation and death by suicide can cut across all of these disorders.

Have you noticed a change in society’s attitude towards mental health?

There is a gradual opening up of discussions, but really, if mental health is what we aim for, what we’re dealing with is mental illness. The fact that we’re talking about suicide recognizes that mental illness kills people. I think we have been a bit reticent to get right down to that level.

What needs to happen yet?

I think the mental health commission, the work of Michael Wilson and others in Canada, has really done a lot to open the conversation about mental illness but we certainly have a long way to go in terms of the funding, the resources that can be put into research in the mental illness. It’s very well known that the financial and economic costs of depression globally are among the top two or three costs in the world but the research community certainly does not receive funding commensurate with the priority.

The numbers

40 seconds Time that passes before another person worldwide commits suicide

800,000+ People who die from suicide every year

15-29 Age group for which suicide is now a leading cause of death globally

20 Number of adults who may have attempted suicide for every one person who dies by suicide

24% Proportion of total deaths in Canada caused by suicide in people age 15-24

11 Canadians who will end their lives by suicide today

9 Suicide’s ranking in Canada’s top 10 causes of death in 2012

$17 million Federal funding for suicide-prevention research since 2010-2011 in Canada.

10 Kidney disease’s ranking in Canada’s top 10 causes of death in 2012

$107.3 million Federal funding for kidney health research since 2010-2011 in Canada.

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